Perioperative management - Intersphincteric resection, open, with transanal colon pull-through and transverse coloplasty pouch

Pathologic lesions in the rectum up to 5cm proximal to the anocutaneous line or which, would not allow the required clearance from the proximal resection line in suprasphincteric anastomosis during low anterior resection; borderline condition between low anterior and abdominoperineal resection.

Tumors invading the sphincter muscles, puborectalis muscle or levator ani muscle. Fecal incontinence irrespective of the tumor.

Relative contraindications:

• Impaired fecal continence

• Endoscopy with biopsy (confirmation of malignancy, complete colonoscopy to confirm/rule out other suspicious findings)
• Possibly air-contrast colon study if complete colonoscopy is not possible
• Ultrasonography/CT (ruling out distant metastases)
• Endorectal ultrasonography, possibly pelvic MRI (local tumor staging)
• Assessment of preoperative and estimation of postoperative sphincteric function
• Possibly urologic and gynecologic diagnostics regarding tumor invasion into neighboring organs

• Orthograde Lavage (intestinal cleansing)
• Prophylactic perioperative antibiotic protocol
• Bladder catheter
• Gastric tube
• Neoadjuvant radio-/chemotherapy, if necessary
• For postoperative follow-up: Tumor markers (CA 19.9, CEA)

• Need for defunctioning loop ileostomy
• Injury to adjacent structures / organs: Bladder, urethra, ureter, seminal vesicles, prostate, vagina
• Hemorrhage requiring allogeneic blood/transfusions
• Anastomotic failure
• Anastomotic stricture
• Fecal incontinence
• Fecal urge incontinence
• Fractionated bowel movement
• Revision surgery

• General anesthesia
• Epidural catheter

• Goligher position (lithotomy position with padded leg rests/stirrups)
• Both arms adducted

Surgeon on the right side of the patient with the first assistant facing him/her. 2^ndassistant changing position between the legs and the left side. Scrub nurse on the left side, with the instrument table above the left leg.

• Leg rests and shoulder rests
• Lone Star Retractor System™

Postoperative analgesia: If possible, start thoracic epidural anesthesia already during surgery and continue postoperatively for 2-5 days.
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management)
Follow this link to the current German guideline on Behandlung akuter perioperativer und posttraumatischer Schmerzen.[Treatment of acute perioperative and post-traumatic pain]

Postoperative care: Remove gastric tube at the end of surgery. Remove any drains on post-operative day 3-4 or, if following the fast track regimen, on postoperative day 1.
Deep venous thrombosis prophylaxis: Unless contraindicated, the high risk of thromboembolism (major abdominal surgery for cancer) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached. Continuing prophylactic medication for deep venous thrombosis for, e.g., 6 weeks is under discussion.
Note: Follow this link to the current German guideline Prophylaxe der venösen Thromboembolie [Guideline on prophylaxis in venous thromboembolism] (VTE).

Ambulation: Unrestricted
Physical therapy: Breathing exercises
Diet: Sipping on postoperative day 1, solid food from day 3-4.
Alternatively, fast track regimen: Fluids and yogurt postoperatively on day of surgery, unrestricted diet on postoperative day 1.
Bowel management: Regular bowel movement is very important, possibly administer weak oral laxatives.
Work disability: Depending on convalescence of each patient